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4 HARRISON AVE - BUILDING INSPECTION .1ZLfC, ' The Commonwealth of Massachusetts. RECEM J 't �g Board of Building Regulations and Standard1%SPECT�CNAL ER 46P OF Massachusetts State Building Code, 780 CMR SALEM e+;�ec��'ar 2011 Building Permit Application To Construct,Repair, Renovate tfiau �Q One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: sa Building Official(Print Name) Signature I ate SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers �I tiUmsoc��., Lla Is this an accepted street?yes_ no :Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: _�n1 f)1 �4A Name(Print) City,State,ZIP }i-akr cin 0I18 91-1 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other 1r1 Specify: II Ul'1. Brief Description of Proposed Work': tylj�J-Ail bjWb CI 05M AAp lap PS) ufV-Hi LCAA:Zm 611 .l1 n - n1 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 5 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Five $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 5 ?-I(B.Ci0' ❑Paid in Full ❑Outstanding Balance Due: i..7I ANT. er5t� G. tit tJ_4 J SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) cue S� �p�ay, �-z, t t (,I� License Number Expiration ate Name of CSL Holder List CSL Type(see below) 31 N A 1-ft U� No.and Street Type Description t ^ �I(t � nZI U Unrestricted Buildin s u to 35,000 cu.ft. U (p R Restricted 1&2 Family Dwelling City/To nw State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 611 Z33 9109 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) I tticln 3Ul I diPY�l T;aCh In I (r3 Registration o Iti y�� HIC Registration Number Expiranon Date HIC Company Narmi or HIC Registhbit Name 71 (Akb fn MX, I) Gb+ n,to IcrF tin r�rr, No.and Street �Ai YIY1 Qr�FY" fJl°IO� 70� -)I�t;• Email address Ci /- owns State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ly No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize UD�c �C—Ulnf"� to act on_mooy__behalf, in all matters relative to work authorized by this building permit application. JJ Printe(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. J0x s tAAA b� Print O is q Au rized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system - Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Aualicant Information Please Print Legibly Name(Business/Orgmigtionnndividual):Amer ic an Building Technologies - Jose Santos Address: 2 Neptune RD #439 City/State/Zip:Boston MA 02128 Phone#: 617 233 8704 Are you an employer?Check the appropriate box: Type of project(required): 1.[3 I am a employer with 5 4. ❑1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t �- ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. q Y P h ❑Building addition [No workers'comp.insurance 5. ❑We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c.152,§I(4),and we have no 12.❑Roof airs insurance required.]t employees.[No workers' 13.EkOther lns u l atlOn comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'oompemation policy information. t Homeowners who submit this mlideva indicating they are doing all work mad then hire outside comraemrs must submit a new affidavit indicating such. :Connecmrs that check this box must mulched m additional sheet showing the name of the subs nmrctors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Hartford 6BO2483-5-13 Policy#or Self-ins. ,L�1ic.#: Expiration Date: (��51/2�,�9�/(�1{�7 Job Site Address: -1 AQ awn '�e City/State/Zip: &U-O 1 1 t 1f�- 0191 o Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby cerd u, der�{h�q�pains and penalties ofpedury that the information provided above is true and correct Cionatu e t ri/c" Date: R7 m \_`5 Phone#: 61 3 8704 Official use only. Do not write in this area,to be completed by city or town official City or Town: PermltfLicense# Issuing Authority(circle am): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Impactor 5.Plumbing Inspector 6.Other Contact Person: Phone#: ._. .—__.r-4f�,tiles:ni..nnrrm��f/..3r`::r/�J:A'niusr.//� -•. O[fwc.>`4o s`ueerr 4Rairs&6nKiurSa R�olatiaa $iratSe ar ft9btraWm"lid for w6,idul am only 014E IMPROVEMENT CONTRACTOR btibm Ibe etpira6on daft, ff fooad refurnta: istratma. 163100 Type_ 41fim(&C04Afaatr Affair and Batinm"latioa trpirdtton Sf1=7 Li.0 10 Park Plena-Suitt 5170 r""' Restoo,MA 02416 AMEkICAH BUILDING T&SINOLOGIES JOSE AWES SAN10$ 1 2 NEPTUNE RO SUtTL 431E tA �..,_._ t,-. tlbSTON, 4 02t'2is Vsdn cre o*ry ,ry'dt raGd wifhotvt sigoatare I�t Masaathuwm 0ep"t l of pabitu S'"Y ® Sowd a}&cihmng RegufatEons arod Star darjs C'�naruumo ivoprn for Urmns :CS-101M -r ,v 31 W. S'dt ft*Thrh MA 02136 ExoiratiOA Cmrrnissmarr tff11f11195 00 American Building Technologies Energy Savings Is Our Specialty 263 Western Avenue-Lynn-MA 01904 Phone-781-598-7125/Fax-781-479-0727 www.americanbuildingtechnologies.com Authorization Letter I,Jose Santos,HIC 163106 and CS-101378 holder hereby give my authorization to Andre Aguiar to act on my behalf regarding the Building Permit Application 4 Harrison Ave, Salem, MA 01970 QR " i4e S tos 8/11/15 `�� CERTIFICATE OF LIABILITY INSURANCE 5/27/2015) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME' Mary 0 Demala Ambrose Insurance Agency, Inc. PHONE FAC M 70 Munroe Street, Suite D EDpAIL A .mdemala@prescottandson.com INSURERS AFFORDING COVERAGE NAIC N Lynn MA 01901 INSURER A Atlantic Casualty Insurance Co. INSURED INSURERB:Torus Specialty Insurance Co. American Building Technologies, Inc. INSURER C:Hart£ord Insurance Co. 263 Western Ave. INsuaea o: INSURER E Lynn MA 01904 INSURER F: COVERAGES CERTIFICATE NUMBERCL14103019581 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER MMIO�YEFF MPM1DDIEYyt� LIMITS TR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 $ COMMERCIAL GENERAL LIABILITY PREMISES Ea N nence $ 100,000 A CLAIMS-MADE OCCUR 035-011680 0/17/2014 0/17/2015 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS AGG $ 2,000,000 POLICY J LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea idart ANV AUTO BODILY INJURY(Per person) $ X ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS 'IN AUTOS AWNED PROPERTY DAMAGE $ HIRED AUTOS To Per accitle t $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION 8331OH141XL 0/17/2014 0/17/2015 $ C WORKERS COMPENSATION X I WC STATU- --TO- E . AND EMPLOYERS'LIABILITY OMy FFICERIMEMBEMITS ER R EXCLUDED?ECU IVE M YIN N/A E L EACH ACCIDENT $ 11000,000 (Mandatory in NH) 6BO2483-5-14 /29/2014 /29/2015 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 6/29/2015 6/29/2016 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insulation Contractor Community Teamwork, Inc, NGrid Corporate Services, LLC, dba Boston Gas Co., dba Colonial Gas Co. , dba Essex Gas Co. , Action Inc. , NStar, and ABCD, Inc. as additional insured general liability, excess liability, auto liability Description of Operations: North Shore Community Action Program CERTIFICATE HOLDER CANCELLATION (978)531-1012 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NSCAP ACCORDANCE WITH THE POLICY PROVISIONS. 119R Foster St. Bldg. 13 AUTHORIZED REPRESENTATIVE Peabody, MA 01960 J S Scholnick/SJG �`�"`'�—� ACORD 25(2010/05) ©1988.2010 ACORD CORPORATION. All rights reserved. INSn2Bnmmnsm Th.Arnon ns—.—A Inns a—roniclnmd.—I,r_ni ACnnn AB (617) 7521570 Contract for Products/Service Work This Agreement is made by and among Eric Blanchard 4 Harrison Ave Salem MA 01970 American Building Technologies(ABT) 2 Neptune Rd, Suite 439 Boston, MA 02128 I. DESCRIPTION OF WORK TO BE PERFORMED 1-Attic air sealing and insulation with blown in cellulose 2- Door sweeps&weather strips 3-Ventilation Total: $5,248.99 Customer Signature: BA � Customer Name: F r A C Date: Contractor Signature: Contractor Name: Date: li �S lJu4 Work OrciCr �'1-2— North Short Community Artems Programs,Irte_ .lob Number:6807 '�- 119 Rear Faster Street,Buildin7,13 Work Order Dale:712 912 0 1 5 Peabody,MA 01960 Ownership;Renter Phome:978-5d14Y767 American ltuilding"I'echnologles Auditor: Rraodoo Doreimgtoo 263 Western Avenue Email:bdorringtougmxmp,ore Lynn MA 01904 CON:781.540.8569 Email:rebeea!n?americaebuad;agtechnola�;:es.tnm Phome:978-531-9767:121 Phone.:781-598-7125 Eric Blanchard ►MAJOR REPAIR FUND- 5750.00 4 Harrison Ave P.1.F.CTRIC 54,498-99 Apt.3 SCR110 Elecirir 5 248.99 Salem 414.01970 Total 978- 01-7099 1sodlord Name:t.ola Eaues Landlord Phone:978.921-2825 Sarew rssue(s):Ashosunc on Pipes 1 I.cad Paine Pmoble A k9orcO.WrIptim, QtF pn.cis To Gommcsfs ml qtg lmml A ltielKne0wall Floor Transition 51 52-82 5143.82 51 51.43.82 seal w/rigid Aud 2part take pictures Dense Pack wlcellulose Kneewalls R-12 cellulose behind 371. 51.94 5719.74 371 .5719.74 ptrmtahte membrane R-19-20 rvmicted-rloprx+floored 217 31.55 5336.3.5 217 S336,35 rill wlcdtmlose R-30 restricted-slopeslfloored rill 377 '51.59 $599.43 377 SS99.43 w/cellulose R-38 unrestricted-settled cellalose 661 >51.65 51,090.65 661 51,090-65 --�_-4ttir Ytii3rTa'tiaa -" -« .- - -' _. ; .:.a:.r: . ., .a.. . .. - ,. .,•. _�..:.... _:.... - . . _ ._-._.._. Reelan ular gable vent 5 Smile $51s.00 5 SSIS00 2 a 12 X 1813[,312X 12 Reetaugular soffit vent 3 530.00 S90A0 3 590.00 Wcatherstrip sQ-lon or equal 3 SSfAll 5153.00 3. S153A0 Date:7J29!_>015 I^age I F 'I Work Order: Job dumber: 6807 Clothes dryer vent including 1 SI00.00 $I00A0 -1 -'3100.00 Exhaust Duct Vent kitlhath fan 3 S100.00 SI00.00 I S1100.00 Mist Measures 90[:NA1 bath fan(new with switch) 1 $750A0 3750.00 1 S75000 3rd 01 home possibly having eltr.problrms make electrician awarr of this and cbeck out before W7.work and wiring bath fan for Attie staling with two-part roam 3 334.00 S252.00 3 S25200 Cut/close attic-koeewall mccess 3 $88-00 S264.00 3 S2fid.M1 Weatherstrip((rlon or equal)atfit I S35.00 S35A0 I S35.10) hatch Boildirtg Permit 1 $100.00 S100.00 1 S100.00 Total SS,748.99 SSJ48.99 Contractor lastructions: Ncfi�rc Starting tom: During 11a::106: 1.Please notify as 24 hours before starting,orschcdulina a job 1.This residence was built before 1978.Isad safe Rdices.are 2.Obtain required building prrmit. requires. 2.Tntat for 13cath R Safcty and Rcpairc caimu+t eroced S25M.011. 3.Davis Samn tine sheets required for ARRA wxA on U5 Vepartmem of Labor Cenified Payton Report Foam WH•347, Additional Cunlractor Instructions: Attic lospectrnu term attached? Yes WA (Cir&One) (:ertificale Of lo$ulatian poslyd? Yes No (circle oft) Date-7/2912015 Pare 2 �I